43: Headache

A 31 year old male presents to the ED with a headache.  He states he rarely gets headaches, but has been having on and off headaches all week.  Tonight, after sexual intercourse, he developed a sudden headache, which is still present.  He denies fever, but has vomited twice.

On exam his vital signs are normal.  You think his neck may be a little stiff, but he can bend his chin to his chest.  The rest of his exam, including a full neurological exam is normal.

CBC and metabolic panel are normal.  The CT scan is read by the radiologist as normal (Image below) so you recommend an LP, but the patient refuses despite all the terrible things you tell him may happen to him.  He says he has been using his iPhone to research headaches and thinks he has a “Post-coital headache”, which he read is not dangerous.

What should you do next?  Is there anyone you should call to help you?

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Answer: Call Neurosurgery

The CT scan actually shows a subarachnoid hemorrhage, so an LP is not necessary.  Additional cuts of the CT are shown below with an arrow pointing to subarachnoid blood on the right side of the brainstem.  The blood looked a little bit like just an extension of the tentorium.

If the CT had been negative, you should call his mother, spouse or PMD to help you convince him to undergo the LP.  You could also tell him it’s like an epidural for childbirth and about 80% of women in this country get an epidural when they have a baby.

The patient was admitted to the ICU with standard treatment for a SAH.  Interestingly his MRA and regular angiogram were both negative.  Evidently this occurs in about 15% of documented subarachnoid bleeds.  He is doing well

EXCERPT ON Subarachnoid Hemorrhage

from

QUICK ESSENTIALS: EMERGENCY MEDICINE

General:      Sudden, max at onset, different than prior headaches
Higher Risk:    Called 911, vomiting, DBP >100, Occipital, neck, LOC, knees buckle, (tinnitus)
Pitfall:           Mild /mod HA, neck only, recurrent:17%, BHT, HTN, EKG:T wave.
Risks:             Asian, polycystic kidneys, Ehlers-Danlos, SLE, smoking
Hunt/Hess:     Classes:  1: mild, HA stops.  2: stiff neck, CN.  3: AMS.  4:   5: coma
LP:                   Measure pressure!  Positive: RBC>100.
False neg:      CT: sentinel bleed, hct<30, >12h, AVM.  LP: <12h, >2wk, visual xanthochromia:50%
Angiogram:    Not as sensitive (85% ) or specific (most aneurysms asymptomatic) for leak as LP.
Indications: dissection?  refuse/can’t LP, >2wk, FH+, PCKD, Marfan, LOC, diplop, Sz, focal
Comps:          Early: hydrocephalus, edema, rebleed ū < 24h.  Late: vasospasm
Rx:               Bed Rest ĉ HOB 30, Nimotop 60q4, Dilantin, Reglan, MS, labetalol: BP>150/80, colace
OR:              Coiling safer than craniotomy in most cases.  (Pravastatin: 1 study with good results)

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